Effect of Formula Feeding and Breastfeeding on Child Growth, Infant Mortality, and HIV Transmission in Children Born to HIV-Infected Pregnant Women Who Received Triple Antiretroviral Therapy in a Resource-Limited Setting: Data from an HIV Cohort Study in India

Feeding modalities, HIV transmission and its predictors among HIV-exposed infants visited Gamo and Gofa zones public health facilities, Southern Ethiopia: a retrospective follow up study

BACKGROUND

Despite the highest (88%) Prevention of Mother-To-Child Transmission (PMTCT) of HIV coverage in Eastern Africa, 50% of new HIV infections in children aged 0-14 years occur in the region.

OBJECTIVE

The aim of this study was to assess the feeding modalities, the rate of HIV transmission and its predictors among HIV exposed infants (HIV-EIs) visited Gamo and Gofa Zones public health facilities, Southern Ethiopia from January 2013 to February 2019.

METHOD AND MATERIALS

Institution-based retrospective follow up study was employed among 450 HIV-EIs having DNA/PCR test results. All infant-mother pair records in selected health facilities were reviewed using a standard data extraction tool from March to July 2019. HIV transmission probabilities were assessed by Kaplan-Meier time-to-event analysis method and log-rank tests were used to compare the risk among different groups. The Cox-proportional hazards model, adjusted on infant feeding modalities and other co-variants was used to identify predictors of HIV transmission, and statistical significance was declared at a p-value of < 0.05.

RESULTS

In total, 383 complete records were analyzed. In the study, 85.6% (95%CI: 81.6%, 89.1%) of HIV-EIs were exclusively breastfed in the first six months. The 18 months probability of infant HIV transmission was 64 (16.7%) (95%CI: 13.1%-20.8%). The risk of HIV-transmission was higher among infants who were delivered at the hospital than health centers/health posts (AHR = 3.07; 95%CI: 1.19, 7.95); discontinued Cotrimoxazole prophylaxis in at least one visit (AHR = 6.32; 95%CI: 3.35, 11.94); did not exclusively breastfeed (AHR = 3.07; 95%CI: 1.72, 5.47) and came from urban areas (AHR = 5.90; 95%CI: 1.40, 24.85).

CONCLUSIONS

The study showed that HIV-EIs had a greater rate of 18 months HIV transmission than the national pooled prevalence. The risk of transmission is higher among infants who do not breastfeed exclusively for the first 6 months, and the risk increases with the number of months spent by breastfeeding. Therefore, strengthening counselling on safer feeding options and Cotrimoxazole prophylaxis use; provision of quality PMTCT service with special focus in hospitals and urban residents were recommended.

Viruses and Human Milk: Transmission or Protection?

Human milk (HM) is considered the best source of nutrition for infant growth and health. This nourishment is unique and changes constantly during lactation to adapt to the physiological needs of the developing infant. It is also recognized as a potential route of transmission of some viral pathogens although the presence of a virus in HM rarely leads to a disease in an infant. This intriguing paradox can be explained by considering the intrinsic antiviral properties of HM. In this comprehensive and schematically presented review, we have described what viruses have been detected in HM so far and what their potential transmission risk through breastfeeding is. We have provided a description of all the antiviral compounds of HM, along with an analysis of their demonstrated and hypothesized mechanisms of action. Finally, we have also analyzed the impact of HM pasteurization and storage methods on the detection and transmission of viruses, and on the antiviral compounds of HM. We have highlighted that there is currently a deep knowledge on the potential transmission of viral pathogens through breastfeeding and on the antiviral properties of HM. The current evidence suggests that, in most cases, it is unnecessarily to deprive an infant of this high-quality nourishment and that the continuation of breastfeeding is in the best interest of the infant and the mother.

Prompt HIV diagnosis and antiretroviral treatment in postpartum women is crucial for prevention of mother to child transmission during breastfeeding: Survey results in a high HIV prevalence community in southern Mozambique after the implementation of Option B+

Objective

World Health Organization recommends promoting breastfeeding without restricting its duration among HIV-positive women on lifelong antiretroviral treatment (ART). There is little data on breastfeeding duration and mother to child transmission (MTCT) beyond 24 months. We compared the duration of breastfeeding in HIV-exposed and HIV-unexposed children and we identified factors associated with postpartum-MTCT in a semi-rural population of Mozambique.

Methods

This cross-sectional assessment was conducted from October-2017 to April-2018. Mothers who had given birth within the previous 48-months in the Manhiça district were randomly selected to be surveyed and to receive an HIV-test along with their children. Postpartum MTCT was defined as children with an initial HIV positive result beyond 6 weeks of life who initiated breastfeeding if they had a first negative PCR result during the first 6 weeks of life or whose mother had an estimated date of infection after the child’s birth. Cumulative incidence accounting for right-censoring was used to compare breastfeeding duration in HIV-exposed and unexposed children. Fine-Gray regression was used to assess factors associated with postpartum-MTCT.

Results

Among the 5000 mother-child pairs selected, 69.7% (3486/5000) were located and enrolled. Among those, 27.7% (967/3486) children were HIV-exposed, 62.2% (2169/3486) were HIV-unexposed and for 10.0% (350/3486) HIV-exposure was unknown. Median duration of breastfeeding was 13.0 (95%CI:12.0–14.0) and 20.0 (95%CI:19.0–20.0) months among HIV-exposed and HIV-unexposed children, respectively (p<0.001). Of the 967 HIV-exposed children, 5.3% (51/967) were HIV-positive at the time of the survey. We estimated that 27.5% (14/51) of the MTCT occurred during pregnancy and delivery, 49.0% (2551) postpartum-MTCT and the period of MTCT remained unknown for 23.5% (12/51) of children. In multivariable analysis, mothers’ ART initiation after the date of childbirth was associated (aSHR:9.39 [95%CI:1.75–50.31], p = 0.001), however breastfeeding duration was not associated with postpartum-MTCT (aSHR:0.99 [95%CI:0.96–1.03], p = 0.707).

Conclusion

The risk for postpartum MTCT was nearly tenfold higher in women newly diagnosed and/or initiating ART postpartum. This highlights the importance of sustained HIV screening and prompt ART initiation in postpartum women in Sub-Saharan African countries. Under conditions where HIV-exposed infants born to mothers on ART receive adequate PMTCT, extending breastfeeding duration may be recommended.

Prolonged Cotrimoxazole Prophylaxis Has No Impact on Child Growth in the First Two Years of Life: Findings from a Randomized Controlled Trial in Botswana

We investigated the impact of prolonged cotrimoxazole prophylaxis on growth in 2848 HIV-exposed uninfected children enrolled in the Mpepu study, a randomized, placebo-controlled trial in Botswana. No significant differences in mean weight-for-age, length-for-age, or weight-for-length z scores between placebo and cotrimoxazole arms were observed overall through 18 months.

Maternal and health care workers' perspectives on exclusive breastfeeding in the context of maternal HIV infection, in Busia county, western Kenya: a mixed methods cross-sectional survey

BACKGROUND

World Health Organization recommends exclusive breastfeeding (EBF) for 6 months with maternal active antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT) of HIV. However, EBF in low resource settings remains low. We explored perspectives of EBF by HIV-infected mothers and health care workers in Busia County with a high prevalence of HIV to understand factors influencing the practice.

METHODS

A mixed methods cross-sectional survey using concurrent quantitative and qualitative data collection methods was conducted at PMTCT clinics. Data on socio-demography, young infant feeding practices, maternal and infant health was collected between February 2013 and August 2015 from 371 purposively sampled HIV-infected mother-infant dyads using a semi-structured questionnaire. Focus group discussions with mothers, in-depth interviews and passive observation of health care workers during interaction with mothers were conducted. Significance of difference between mothers practicing EBF or not was tested by Chi-square and Fisher's exact tests setting significance level at 5%. Qualitative data was coded and content analyzed to generate themes.

RESULTS

Three hundred and forty-nine (94%) mothers practiced EBF. Maternal comprehension of EBF to PMTCT of HIV influenced choice and practice of EBF (P value = 0.019 and < 0.001 respectively). Health care workers emphasized adherence to ART and offered nutritional supplementation during EBF. Health care workers' nutritional counseling in the context of maternal HIV was poor. Mentor mothers shared their experiences with mothers and offered live case demonstrations of their successfully EBF, healthy and HIV-uninfected children. The main threats to EBF were teenage motherhood, low maternal education and working during EBF.

CONCLUSIONS

EBF among HIV-infected mothers in Busia County, Kenya was high. Health education and counselling by health care workers, maternal comprehension of ART adherence to PMTCT of HIV, nutritional supplementation and mentor mothers' peer counseling using live case demonstrations of HIV-uninfected EBF children promoted and sustained practice of EBF for 6 months. Teenage motherhood, low maternal education and having to work threatened EBF.

Vertical transmission of HIV, Where do we stand ? Study done in PPTCT center - in a tertiary level of hospital of Western Rajasthan

Background

Human immunodeficiency virus (HIV) infection in pregnant women has an important role in its spread to the pediatric population through vertical transmission. Effective utilization of Prevention of Parent to Child Transmission (PPTCT) services can reduce this spread. This study aims to determine the vertical transmission of HIV, the seroprevalence of HIV in antenatal women, demographic factors of seropositive women, and utilization of PPTCT services to minimize the risk of mother-to-child transmission.

Methods

This study was conducted to assess vertical transmission of HIV in the newborn of HIV pregnant women attending antenatal clinic (ANC) of a tertiary care hospital from August 2014 to December 2020. Pretest counseling, HIV testing, and posttest counseling were done as per National AIDS Control Organization (NACO) guidelines. Antiretroviral prophylaxis was given to seropositive women and their children. Analysis of demographic data of seropositive women and assessment of the utilization of PPTCT services were done according to available records.

Results

In the study time, 139,619 new antenatal registrations were there, 68.21% of women attended pretest counseling and of them, 95.28% gave consent for HIV testing. Out of which, 0.14% were reported as HIV seropositive in PPTCT (tested according to NACO guidelines). In the study time, a total of 188 HIV-positive deliveries were conducted in our institute. Out of which, 144 (76.6%) were ANC-booked patients and 44 (23.4%) were unbooked patients and directly came in labor, deliveries were conducted according to NACO guidelines and all newborns were given nevirapine syrup. All newborns were followed up until 18 months and in study time, 78 dry blood samples (DBSs) were sent for DNA polymerase chain reaction (PCR) detection and all were reported negative by the reference laboratory at AIIMS, New Delhi.

Conclusions

Adherence to testing, treatment, and follow-up in the antenatal and postnatal period can minimize the risk of HIV transmission from mother to child.

Seroprevalence and Efficacy of Prevention of Parent to Child Transmission Program Over a Decade in a Tertiary Care Hospital in Mumbai, Maharashtra

Background

Parent to child transmission is the major mode of spread of HIV. An effective national health program (PPTCT) has been designed under NACO which helps in reducing the spread of HIV by vertical transmission and improving the life of the women and her baby.

Methods

A retrospective study was done at a tertiary care hospital, including pregnant women registered and delivered, and those who came directly in labour at the hospital during a period of 10 years from January 2010 to December 2019. Pretest counselling, HIV testing, Post-test counselling were done, and antiretroviral prophylaxis was given as per the NACP guidelines. Sociodemographic characteristics, obstetric outcome and efficacy of PPTCT services were analysed.

Results

Out of the 63,947 antenatal mothers included, 61,061 (95.4%) accepted HIV testing. 177 of these tested positive (0.289%) with a significant reduction in the seroprevalence over the decade. Majority of seropositive women were primigravida; housewives from urban areas, from low income and educational background and with no history of any contraceptive use. Out of 718 live births, the MTCT rate was found to be 4.5% at 6 weeks over the whole decade and was noted to be 1.8 % at 18 months which is well within the goal of PPTCT program and hence elucidating the success. Seventy-four spouses of the 177 seropositive women tested positive, 55 tested negative and 49 did not undergo the HIV testing. Decline in the number of partners not undergoing testing was elicited. The discordant couple rate in the study was 31% and showed variable trend over the decade.

Conclusions

Our study has observed an overall increase in efficacy of PPTCT in terms of increased utilization of PPTCT through the decade, decrease in the vertical transmission and seroprevalence rate, increase in the acceptance rates of HIV testing by partner almost conquering the goal of NACO.

Effect on growth of exposure to maternal antiretroviral therapy in breastmilk versus extended infant nevirapine prophylaxis among HIV-exposed perinatally uninfected infants in the PROMISE randomized trial

Background

Malnutrition is highly prevalent in HIV-exposed perinatally uninfected infants (HEUs) increasing the risk of morbidity and mortality throughout the life course. We set out to compare the effect of postnatal exposure to maternal antiretroviral therapy (mART) in breastmilk versus infant Nevirapine prophylaxis (iNVP) on somatic growth of HEUs in the randomized PROMISE trial.

Methods and findings

We randomized 2431 mothers with HIV and their 2444 HEUs from six African countries and India 6–14 days after delivery to mART or iNVP for prevention of breastmilk HIV transmission. The mART regimen contained tenofovir/emtricitabine (99%) plus lopinavir/ritonavir. Infant growth parameters were compared at postnatal week 10, 26, 74 and 104 using World Health Organization (WHO) z-scores for length-for-age (LAZ), weight-for-age (WAZ), and head circumference-for-age (HCAZ). Week 26 LAZ was the primary endpoint measure. Student T-tests compared mean LAZ, WAZ, and HCAZ; estimated mean and 95% confidence interval (CI) are presented.

Maternal and infant baseline characteristics were comparable between study arms. The estimated median breastfeeding duration was 70 weeks. After a mean follow-up of 88 weeks, mean LAZ and WAZ were below the WHO reference population mean at all timepoints, whereas mean HCAZ was not. The mART and iNVP arms did not differ for the primary outcome measure of LAZ at week 26 (p-value = 0.39; estimated mean difference (95%CI) of -0.05 (-0.18, 0.07)) or any of the other secondary growth outcome measures or timepoints (all p-values≥0.16). Secondary analyses of the primary outcome measure adjusting for week 0 LAZ and other covariates did not change these results (all p-values≥0.09). However, infants assigned to mART were more likely to have stunting compared to iNVP infants at week 26 (odds ratio (95% CI): 1.28 (1.05, 1.57)).

Conclusions

In HEUs, growth effects from postnatal exposure to mART compared to iNVP were comparable for measures on length, weight and head circumference with no clinically relevant differences between the groups. Despite breastfeeding into the second year of life, length and weight were below reference population means at all ages in both arms. Further investment is needed to optimize postnatal growth of infants born to women with HIV.

Clinical trial registration

ClinicalTrials.gov number NCT01061151.

HIV-free survival among breastfed infants born to HIV-positive women in northern Uganda: a facility-based retrospective study

Introduction

the HIV-free survival rate is the gold-standard measure of the effectiveness of interventions towards prevention of mother-to-child transmission of HIV in any setting. However, data on HIV-free survival among the HIV-exposed infants followed up in most low-resource settings are lacking. We determined the HIV-free survival among breastfed infants in two tertiary facilities in a resource-poor setting in northern Uganda.

Methods

we conducted a retrospective cohort study in May 2019 and retrospectively reviewed records of HIV-exposed infants registered in 2014 through 2016 at two tertiary facilities in northern Uganda. We analyzed data using SPSS v16 software package. The chi-square and Student t-tests were used to compare factors among infant groups. Multivariate logistic regression analysis was used to determine factors independently associated with HIV-free survival. P-value <0.05 was considered for statistical significance.

Results

majority of the infants were males 55.6% (203/365) and 98.6% (360/365) received nevirapine prophylaxis. A total of 345 (94.5%) infants were exclusively breastfed, only 100/345 (29.0%) of whom were exclusively breastfed for at least 6 months, while the breastfeeding status of 44/345 (12.8 %) infants could not be ascertained. The overall HIV-free survival rate was 93.7% (342/365), while 2.7% (10/365) were HIV-infected and 3.6% (13/365) died. Infants´ age at enrolment in care (aOR 5.20, p=0.008) and treatment facility (aOR 3.76, p=0.027) were the independent determinants of HIV-free survival.

Conclusion

the HIV-free survival rate among the breastfed infants in the study setting marginally falls short of the recommended standard, thus calling for more efforts to improve survival.

Anti-retroviral therapy failure in HIV-1 infected pregnant women and its associated risk of HIV transmission

BACKGROUND

The HIV perinatal transmission in India even after interventions is still high. The anti-retroviral therapy failure rate and the risk of HIV vertical transmission to infants from women with failed treatment during pregnancy also largely remains unevaluated.

METHODS

This is a prospective, observational and follow-up study of 18 months to determine the association of ART failure in pregnant women and the subsequent risk of HIV transmission to their infants. A total of 81 mothers were evaluated for ART success/failure by analysing their viral loads.

RESULTS

Analyses revealed that a high percentage (19.75%) of women on ART had high viral loads, while the overall HIV transmission rate to the infants was 8.64%. The rate of transmission from women with high viral load was significantly high compared to women with low viral load (37.5% vs. 1.54%; p = 0.0015). CD₄ level was not associated with HIV transmission. However, CD₄ levels in women, who had successful or failed ART, were significantly different (p = 0.0031). Factors such as mother's age, baby's sex and weight as well as delivery mode were not associated with HIV transmission, however, breastfeeding and viral loads were found to be independently associated with HIV transmission to the neonates.

CONCLUSIONS

This study highlights that a significant proportion of women on ART had impaired viral load control. The rate of HIV transmission to infants was also significantly high among these women. This warrants viral load monitoring of HIV infected women to reduce the overall transmission to the infants.

Acceptability of donor breastmilk banking among health workers: a cross-sectional survey in Zimbabwean urban settings

BACKGROUND

The World Health Organization (WHO) recommends that donor human milk is superior to artificial infant formula in situations where the baby cannot feed on the mother's breastmilk. The purpose of this study was to determine the acceptability of donor human milk banking among health workers in Zimbabwean urban settings.

METHODS

A cross sectional study was conducted among 535 health workers and 15 key informants. Three referral hospitals were purposively selected and systematic random sampling was used to select the health workers. The study was conducted between October 2017 and October 2018.

RESULTS

The concept of donor human milk banking was acceptable among health workers. One-third (31%) of the study participants reported that they would accept donor breastmilk for their children while 56% of them would encourage their clients to donate breastmilk. Acceptance of donor human milk banking was associated with a high level of knowledge on breastmilk banks (p = 0.009) and the study participants' health profession (p = 0.001). Clinical staff were more receptive to donor human milk banking compared to non-clinical health workers. Donor human milk banking was not associated with religion (p = 0.498) or marital status (p = 0.714).

CONCLUSIONS

The results showed that health workers and policy informers would accept the establishment of breastmilk banks subject to resource availability. Commitment to the establishment of breastmilk banks was moderately acceptable among opinion leaders responsible for spearheading health and nutrition policies.

Structural vulnerabilities and breastfeeding among female sex workers in Mumbai

Breastfeeding has numerous health, environmental, and economic benefits, and the promotion and support of breastfeeding has been at the centre of efforts from many global organizations such as WHO and UNICEF to promote maternal and child health. Interventions developed from such policies tend to be inaccessible to those who are economically marginalized, however, and thus may further inequities. Understanding the lived experiences of women occupying this segment of society, such as sex workers, illuminates the social and structural determinants of breastfeeding and how they constitute structural vulnerability that renders breastfeeding difficult. This qualitative study explores breastfeeding practices and decisions among sex workers in Mumbai and the factors shaping their experiences. We look at proximal factors—those that women directly indicate as influencing their breastfeeding decision‐making or behaviour, and distal factors—macrolevel forces identified by the women, as indication of their structural vulnerability, particularly in relationship to the decision to initiate and sustain breastfeeding. We conclude with discussing the need to promote appropriate infant feeding practices through culturally responsive interventions and mechanisms, taking both proximal and distal factors into account, to work towards equity in health outcomes.

Growth of HIV-uninfected children born to HIV-infected mothers in Guangdong, China: an 18-month longitudinal follow-up study

Background

To evaluate the early growth (weight and length) of HIV-exposed uninfected (HEU) children from the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) program in Guangdong Province, China.

Methods

A total of 731 HEU children were longitudinally followed up at 7 time points, with anthropometric measurement conducted of weight and length (supine) in the first 18 months. Z scores were calculated, with and without adjustment for gestational age.

Results

A total of 708 HEU children were included in the final follow-up cohort, and 105 (14.83%) children completed all 7 follow-up visits. The mean of adjusted weight-for-age Z scores in these children was above zero and showed a decreasing trend in 18 months. The mean of adjusted length-for-age Z scores showed a decreasing trend and was above zero in the first 12 months; this declined to under zero at age 18 months. The proportion of underweight was 0.28–2.19% and that of stunting was 0.71–4.63% at each follow-up month-age. Slower growth in HEU children was associated with no sustained food subside after 6 month, mothers’ hemoglobin content less than 100 g/L during pregnancy, preterm birth, and low birth weight (p < 0.05).

Conclusions

HEU children could catch up to WHO growth standards in first 18 months in Guangdong; however, growth declined after 12 months, and these children need sustained nutritional support.

Impact of antiretroviral treatment on height evolution of HIV infected children

BACKGROUND

Antiretroviral treatment (ART) has been shown to have a beneficial effect on the weight evolution but its effect on height remains unclear. We described patterns of height evolution and identified predictors of catch-up growth in HIV-infected children on ART.

METHODS

To describe the height evolution from birth to adulthood, we developed a nonlinear mixed effect model using data from perinatally HIV-infected children who initiated ART from 1999 to 2013 in a prospective cohort study in Thailand. The main covariates of interest were: sex, ART regimen (dual nucleoside reverse-transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor (NNRTI)-, or protease inhibitor (PI)-based), baseline CD4 percentage, HIV-RNA load and CDC HIV Classification stage and occurrence of AIDS-defining events.

RESULTS

A total 477 children (43% boys) contributed 18,596 height measurements over a median duration of 6.3 years on ART (interquartile range, 3.0 to 8.3). At ART initiation, median age was 6.2 years (1.8 to 9.6), 16% of children were underweight (weight-for-age z-score < - 2), 49% presented stunting (height-for-age z-score < - 2), and 7% wasting (weight-for-height z-score < - 2). The most frequent regimen at ART initiation was NNRTI-based (79%). A model with 4 components, birth length and 3 exponential functions of age accounting for the 3 growth phases was developed and show that the height-growth velocity was inversely associated with the age at ART initiation, the adult height was significantly lower in those who had experienced at least one AIDS-defining event while, as expected, the model found that adult height in females was lower than in males. Age at ART initiation, type of ART regimen, CDC stage, CD4 percentages, and HIV-RNA load were not associated with the final height.

CONCLUSIONS

The younger the children at ART initiation, the greater the effect on height-growth velocity, supporting the World Health Organization's recommendation to start ART as early as possible. However, final adult height was not linked to the age at ART initiation.

Incidence, prevalence and associated factors of mother-to-child transmission of HIV, among children exposed to maternal HIV, in Belgaum district, Karnataka, India

BACKGROUND

India lacks data on the incidence of Paediatric HIV. In 2010, the Indian Council of Medical Research commissioned a task force study to estimate the paediatric HIV burden in Belgaum district, Karnataka, India. We estimated the HIV incidence, prevalence and associated risk factors of mother to child transmission of HIV among children exposed to maternal HIV by age 24 months.

METHODS

We included Belgaum resident pregnant women who tested HIV positive between January 1st, 2011 and May 31st, 2013 and who provided consent. Their babies were tested for HIV at three time intervals using DNA PCR dry blood spot (DBS) method at 6-10 weeks and 6-9 months, and using Antibody tests at 18-24 months of age. We estimated cumulative incidence using survival analysis that considered censoring of cases and prevalence rates of HIV by age 24 months. Using competing-risk survival regression model, we examined the correlates of transmission of HIV among babies exposed to maternal HIV.

RESULTS

Among 487 children of HIV positive mothers recruited in the study, the cumulative incidence rate by 24 months of age was 4.8 per 1000 person months [95% CI: 3.5-6.6]. The HIV prevalence rate among babies exposed to maternal HIV until 24 months was 7.8% [95% CI: 5.7-10.7]. Mother's age above 30 years, and breastfeeding duration of more than six months were factors that significantly increased the HIV transmission; adjusted hazard ratio (AHR) 6.98 [95% CI: 1.73-28.16] and 5.28 [95% CI, 1.75-15.90], respectively. The risk of MTCT was significantly reduced if both mother and baby had received Nevirapine at delivery [AHR 0.25; 95%CI: 0.10-0.61] and if either mother or baby had been given Nevirapine at delivery [AHR 0.12; 95%CI: 0.03-0.49].

CONCLUSION

The study findings suggest that mother's age above 30 years and breastfeeding beyond 26 weeks is associated with higher rates of HIV transmission from mother to child. It confirms the benefits of providing anti-retrovirals (Nevirapine) in reducing mother to child transmission of HIV. Effective strategies to promote safe infant feeding practices, including avoidance of mixed feeding beyond 26 weeks among HIV infected mothers, is critical to reduce incidence of paediatric HIV in India.

HIV Exposure and Formula Feeding Predict Under-2 Mortality in HIV-Uninfected Children, Botswana

OBJECTIVES

To prospectively assess rates and detailed predictors of morbidity and mortality among HIV-exposed uninfected children and HIV-unexposed children in Botswana in a more recent era.

STUDY DESIGN

We enrolled HIV-infected and HIV-uninfected mothers and their children in the prospective observational Tshipidi study at 2 sites (1 city and 1 village) in Botswana from May 2010-July 2012. Live-born children and their mothers were followed for 24 months postpartum. Detailed sociodemographic data, health, and psychosocial characteristics were collected at baseline and prospectively, and health outcomes ascertained. Mothers chose infant feeding method with counselling.

RESULTS

A total of 893 live-born HIV-uninfected children (436 HIV-exposed uninfected, 457 HIV-unexposed) were followed. HIV-infected mothers had a median CD4 count of 410 cells/mm3, 32% took 3-drug antiretroviral treatment during pregnancy, 67% took only zidovudine, and 1% took <2 weeks of any antiretrovirals antepartum. Twenty four-month vital status was available for 888 (99.4%) children. HIV-exposed uninfected children had a significantly higher risk of death compared with children of HIV-uninfected mothers (5.0% vs 1.8%) (adjusted hazard ratio 3.27, 95% CI 1.44-7.40). High collinearity between maternal HIV status and child feeding method precluded analysis of these factors as independent predictors of mortality. Preterm birth, low birth weight, and congenital anomaly were also associated with mortality (in separate analyses), but maternal socioeconomic factors, depression, substance use, and social support were not significant predictors.

CONCLUSIONS

The strongest predictors of 24-month mortality among children in Botswana were HIV exposure and formula feeding, although the relative contribution of these factors to child health could not be separated.

Does U=U for breastfeeding mothers and infants? Breastfeeding by mothers on effective treatment for HIV infection in high-income settings

Can the campaign Undetectable=Untransmittable (U=U), established for the sexual transmission of HIV, be applied to the transmission of HIV through breastfeeding? European AIDS Clinical Society and, to some extent, American guidelines now state that mothers with HIV who wish to breastfeed should be supported, with increased clinical and virological monitoring. This Viewpoint summarises existing evidence on transmission of HIV through breastfeeding, differences in HIV dynamics and viral load between breastmilk and plasma, and the effects of antiretroviral therapy on infants. At present, insufficient evidence exists to make clear recommendations for the required frequency of clinical and virological monitoring for mother and infant in a breastfeeding relationship or for the action to be taken in the event of viral rebound. We propose a roadmap for collaborative research to provide the missing evidence required to enable mothers who wish to breastfeed to make a fully informed choice.

Las semanas de gestación como factor asociado a la práctica de la lactancia materna inmediata

Introducción: iniciar la lactancia tempranamente es crucial para aprovechar el periodo sensitivo del recién nacido y la cascada hormonal materna inmediata al posparto, que en conjunto favorecen la continuidad de la lactancia durante el desarrollo del niño. Sin embargo, existen factores que pueden afectar la realización de la lactancia materna inmediata (LMI) con consecuencias que afectan la salud.Objetivo: determinar si existe relación entre la LMI y las características del control prenatal, del parto y de tipo socioeconómico.Material y métodos: estudio de casos y controles. Se aplicaron encuestas a mujeres con hijos entre 6 y 24 meses de edad. El muestreo fue no probabilístico. Se compararon las medias a través de la t de student, se buscaron asociaciones a través de correlación de Spearman y Odds ratio.Resultados: las semanas de gestación (SDG) tuvieron una media inferior en el grupo de mujeres que realizaron LMI (p=0,023). Las mujeres con mayores ingresos económicos realizaron menos LMI [Rho= -0.28 (p <0.05)] y a menos SDG aumenta la práctica de LMI [Rho= -0,35 (p <0,05)]. Nacer con más de 38 SDG se relaciona con menor realización de LMI [OR= 0.16 (IC 0,04-0,64)].Conclusiones: mientras que el menor ingreso económico y escolaridad de la madre se relacionan con menor práctica de LMI, cuando el parto se da antes de las 38 SDG la probabilidad aumenta.

Role of HIV exposure and infection in relation to neonatal GBS disease and rectovaginal GBS carriage: a systematic review and meta-analysis

Streptococcus agalactiae (GBS) is the leading cause worldwide of neonatal sepsis. We sought to assess to which extent HIV exposure of neonates is associated with GBS neonatal disease. Furthermore, we assessed to which extent HIV infection in women is associated with maternal rectovaginal GBS carriage, the single most important risk factor for GBS neonatal disease. We searched Pubmed, Embase, and Web of Science for studies assessing the association between neonatal GBS disease and HIV-status of the mother and studies that assessed the association between rectovaginal GBS colonization and HIV status in women. HIV-exposed uninfected neonates were more than twice as likely to have neonatal GBS disease compared to unexposed neonates. HIV-exposed neonates were not at increased risk for early-onset neonatal disease, but were 4.43 times more likely to have late-onset neonatal GBS disease. There was no significant association between HIV infection status and rectovaginal GBS carriage. Public health interventions preventing neonatal GBS disease are urgently needed for the increasing group of HIV-exposed neonates. A framework integrating and explaining our findings highlights opportunities for the clinical practice and global health policy to prevent disease. Well-designed studies should clarify the relation between HIV-status and GBS carriage.

Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis

Introduction: To systematically review the literature on mother-to-child transmission in breastfed infants whose mothers received antiretroviral therapy and support the process of updating the World Health Organization infant feeding guidelines in the context of HIV and ART.

Methods: We reviewed experimental and observational studies; exposure was maternal HIV antiretroviral therapy (and duration) and infant feeding modality; outcomes were overall and postnatal HIV transmission rates in the infant at 6, 9, 12 and 18 months. English literature from 2005 to 2015 was systematically searched in multiple electronic databases. Papers were analysed by narrative synthesis; data were pooled in random effects meta-analyses. Postnatal transmission was assessed from four to six weeks of life. Study quality was assessed using a modified Newcastle-Ottawa Scale (NOS) and GRADE.

Results and discussion: Eleven studies were identified, from 1439 citations and review of 72 abstracts. Heterogeneity in study methodology and pooled estimates was considerable. Overall pooled transmission rates at 6 months for breastfed infants with mothers on antiretroviral treatment (ART) was 3.54% (95% CI: 1.15–5.93%) and at 12 months 4.23% (95% CI: 2.97–5.49%). Postnatal transmission rates were 1.08 (95% CI: 0.32–1.85) at six and 2.93 (95% CI: 0.68–5.18) at 12 months. ART was mostly provided for PMTCT only and did not continue beyond six months postpartum. No study provided data on mixed feeding and transmission risk.

Conclusions: There is evidence of substantially reduced postnatal HIV transmission risk under the cover of maternal ART. However, transmission risk increased once PMTCT ART stopped at six months, which supports the current World Health Organization recommendations of life-long ART for all.

Infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital East Gojam zone, North West Ethiopia

Introduction

The dilemma posed between lifesaving benefit and risk of transmission through breast feeding complicates infant feedings among communities grossly affected by HIV/AIDS. According to the world health organization’s guideline which was revised in 2010, exclusive breast feeding and exclusive replacement feeding are the recommended infant feeding practices for HIV positive mothers. The aim of this study was to assess infant feeding practice and associated factors among HIV positive mothers in Debre Markos Referral Hospital, North West Ethiopia.

Methods

An institutional based cross sectional study was conducted from May to September 2013. A Randomly selected 260 HIV positive mothers were included. The data were collected by using a pretested and structured questionnaire. Bivariate and multivariate analysis were performed to check association and to control confounders.

Results

From a total of 260 HIV positive mothers, 85.8% of them were feeding their children based on the recommended feeding way of infant feeding practice with the remaining percentage 14.2% were practicing mixed feeding. In multivariate analysis mothers attending high school and above AOR = 5.3 [95% CI = 1.25-22.1], having antenatal care follow up AOR = 5.5 [95% CI = 1.5-20.16], being on anti-retro viral therapy AOR = 6.5 [95% CI = 1.88-22.51] and disclosure of HIV status AOR = 7.1 [95% CI = 1.26-39.76] were found to be independently associated with infant feeding practice.

Conclusion

This study revealed that large proportion of HIV positive mothers had followed the recommended infant feeding practice and significantly high number of mothers had practiced mixed feeding. Educating mothers, increasing ANC utilization, counseling mothers to start ART, encouraging and supporting mothers to disclose their HIV status were recommended.

HIV-free survival at 12-24 months in breastfed infants of HIV-infected women on antiretroviral treatment

Objective

To provide estimates of HIV‐free survival at 12–24 months in breastfed children by maternal ART (6 months or lifelong) to inform WHO HIV and Infant Feeding guidelines.

Methods

Eighteen studies published 2005–2015 were included in a systematic literature review (1295 papers identified, 156 abstracts screened, 55 full texts); papers were analysed by narrative synthesis and meta‐analysis of HIV‐free survival by maternal ART regimen in a random effects model. We also grouped studies by feeding modality. Study quality was assessed using a modified Newcastle–Ottawa Scale (NOS) and GRADE.

Results

The pooled estimates for 12‐month HIV‐free survival were 89.8% (95% confidence interval, CI: 86.5%, 93.2%) for infants of mothers on ART for 6 months post‐natally (six studies) and 91.4% (95% CI 87.5%, 95.4%) for infants of mothers on lifelong ART (three studies). Eighteen‐month HIV‐free survival estimates were 89.0% (95% CI 83.9%, 94.2%) with 6 months ART (five studies) and 96.1% (95% CI 92.8%, 99.0%) with lifelong ART (three studies). Twenty‐four‐month HIV‐free survival for infants whose mothers were on ART to 6 months post‐natally (two studies) was 89.2% (95% CI 79.9%, 98.5%). Heterogeneity was considerable throughout. In four studies, HIV‐free survival in breastfed infants ranged from 87% (95% CI 78%, 92%) to 96% (95% CI 91%, 98%) and in formula‐fed infants from 67% (95% CI 35.5%, 87.9%) to 97.6% (95% CI 93.0%, 98.2%).

Conclusion

Our results highlight the importance of breastfeeding for infant survival and of ART in reducing the risk of mother‐to‐child HIV transmission and support the WHO recommendation to initiate ART for life immediately after HIV diagnosis.

Clinical outcomes of HIV-exposed, HIV-uninfected children in sub-Saharan Africa

OBJECTIVE

HIV-exposed but HIV-uninfected (HEU) children are widely considered at increased risk of mortality and morbidity. Recent advances in prevention of mother-to-child HIV transmission (PMTCT) strategies, incorporating life-long universal maternal antiretroviral therapy (ART, "Option B+") with extended breastfeeding, may improve HEU child health substantially. We critically reviewed reports of mortality/morbidity among HEU and HIV-unexposed (HU) children in sub-Saharan Africa.

METHODS

We searched Medline, EMBASE, CINAHL, PsycINFO, Academic Search Premier, Global Health & Psychosocial Instruments databases, conference abstracts, and reference lists for longitudinal studies from sub-Saharan Africa reporting mortality and clinical morbidity among HIV-uninfected children aged ≤10 years, by maternal HIV status. Studies were appraised by Newcastle-Ottawa Scale and ACROBAT-NRSI. Due to substantial heterogeneity of study designs, populations and results (I(2) = 75%), data were not synthesised.

RESULTS

We included 37 reports (28 studies, 11 164 HEU children); methodological and reporting quality were variable. Most reports came from settings without universal access to maternal ART (n = 35). Results were conflicting, with some studies indicating increased risk of mortality, hospitalisation and/or under-nutrition among HEU children, while others found no evidence of increased risk. In subanalyses, improved maternal health, ART use and breastfeeding were strongly protective for all outcomes. Only 39% (11/28) of studies adjusted for major confounders. Reports from settings using universal maternal ART with breastfeeding (n = 2) found no differences in growth or development but did not report mortality or infectious morbidity.

CONCLUSIONS

The existing literature provides little insight into HEU child health under recently adopted PMTCT strategies. There is a need for robust comparative data on HEU and HIV-unexposed child health outcomes under Option B+; optimising breastfeeding practices and increasing maternal use of ART should be urgent public health priorities.

Treatment Failures and Excess Mortality Among HIV-Exposed, Uninfected Children With Pneumonia

BACKGROUND

Human immunodeficiency virus (HIV)-exposed, uninfected (HIV-EU) children are at increased risk of infectious illnesses and mortality compared with children of HIV-negative mothers (HIV-unexposed). However, treatment outcomes for lower respiratory tract infections among HIV-EU children remain poorly defined.

METHODS

We conducted a hospital-based, prospective cohort study of N = 238 children aged 1-23 months with pneumonia, defined by the World Health Organization. Children were recruited within 6 hours of presentation to a tertiary hospital in Botswana. The primary outcome--treatment failure at 48 hours--was assessed by an investigator blinded to HIV exposure status.

RESULTS

Median age was 6.0 months; 55% were male. One hundred fifty-three (64%) children were HIV-unexposed, 64 (27%) were HIV-EU, and 20 (8%) were HIV-infected; the HIV exposure status of 1 child could not be established. Treatment failure at 48 hours occurred in 79 (33%) children, including in 36 (24%) HIV-unexposed, 30 (47%) HIV-EU, and 12 (60%) HIV-infected children. In multivariable analyses, HIV-EU children were more likely to fail treatment at 48 hours (risk ratio [RR]: 1.83, 95% confidence interval [CI]: 1.27-2.64, P = .001) and had higher in-hospital mortality (RR: 4.31, 95% CI: 1.44-12.87, P = .01) than HIV-unexposed children. Differences in outcomes by HIV exposure status were observed only among children under 6 months of age. HIV-EU children more frequently received treatment with a third-generation cephalosporin, but this did not reduce the risk of treatment failure in this group.

CONCLUSIONS

HIV-EU children with pneumonia have higher rates of treatment failure and in-hospital mortality than HIV-unexposed children during the first 6 months of life. Treatment with a third-generation cephalosporins did not improve outcomes among HIV-EU children.

Counselling services in prevention of mother-to-child transmission (PMTCT) in Delhi, India: an assessment through a modified version of UNICEF-PPTCT tool

The study aims to assess the counselling services provided to prevent mother to child transmission of HIV (PMTCT) under the Indian programme of prevention of parent-to-child transmission of HIV (PPTCT). Five hospitals in Delhi providing PMTCT services were randomly selected. A total of 201 post-test counselled women were interviewed using a modified version of the UNICEF-PPTCT evaluation tool. Knowledge about HIV transmission from mother-to-child was low. Post-test counselling mainly helped in increasing the knowledge of HIV transmission; yet 20%–30% of the clients missed this opportunity. Discussion on window period, other sexually transmitted diseases and danger signs of pregnancy were grossly neglected. The PMTCT services during the antenatal period are feasible and agreeable to be provided; however, certain aspects, like lack of privacy, confidentiality of HIV status of the client, counsellor’s ‘hurried’ attitude, communication skills and discriminant behaviour towards HIV-positive clients, and disinterest of clients in the counselling, remain as gaps. These issues may be addressed through refresher training to counsellors with an emphasis on social and behaviour change communication strategies. Addressing attitudinal aspects of the counsellors towards HIV positives is crucial to improve the quality of the services to prevent mother-to-child transmission of HIV.

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India

INTRODUCTION

India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.

METHODS

We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.

RESULTS

A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.

CONCLUSIONS

The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Severe acute malnutrition and infection

Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.

The impact of the milk glycobiome on the neonate gut microbiota

Human milk is a complete source of nourishment for the infant. Exclusive breastfeeding not only sustains the infant's development but also guides the proliferation of a protective intestinal microbiota. Among the many components of milk that modulate the infant gut microbiota, the milk glycans, which comprise free oligosaccharides, glycoproteins, and glycolipids, are increasingly recognized as drivers of microbiota development and overall gut health. These glycans may display pleiotropic functions, conferring protection against infectious diseases and also acting as prebiotics, selecting for the growth of beneficial intestinal bacteria. The prebiotic effect of milk glycans has direct application to prevention of diseases such as necrotizing enterocolitis, a common and devastating disease of preterm infants. In this article, we review the impact of the human (and bovine) milk glycome on gut health through establishment of a milk-oriented microbiota in the neonate.

Induction with lopinavir-based treatment followed by switch to nevirapine-based regimen versus non-nucleoside reverse transcriptase inhibitors-based treatment for first line antiretroviral therapy in HIV infected children three years and older

BACKGROUND

The World Health Organization recommends non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based antiretroviral therapy (ART) for children three years and older. In younger children, starting ART with lopinavir boosted with ritonavir (LPVr) results in lower risk of virological failure, but data in children three years and older are scarce, and long-term ART with LPVr is problematic in resource-poor settings.

METHODOLOGY

Retrospective cohort of children three years and older who started triple ART including LPVr or a NNRTI between 2007 and 2013 in a rural setting in India. Children who started LPVr were switched to nevirapine-based ART after virological suppression. We analysed two outcomes, virological suppression (HIV-RNA <400 copies/ml) within one year of ART using logistic regression, and time to virological failure (HIV-RNA >1000 copies/ml) after virological suppression using Cox proportional hazard regression. A sensitivity analysis was performed using inverse probability of treatment weighting (IPTW) based of propensity score methods.

FINDINGS

Of 325 children having a viral load during the first year of ART, 74/83 (89.2%) in the LPVr group achieved virological suppression versus 185/242 (76.5%) in the NNRTI group. In a multivariable analysis, the use of LPVr-based ART was associated with higher probability of virological suppression (adjusted odds ratio 3.19, 95% confidence interval [CI] 1.11-9.13). After IPTW, the estimated risk difference was 12.2% (95% CI, 2.9-21.5). In a multivariable analysis including 292 children who had virological suppression and available viral loads after one year of ART, children switched from LPVr to nevirapine did not have significant higher risk of virological failure (adjusted hazard ratio 1.18, 95% CI 0.36-3.81).

CONCLUSIONS

In a cohort of HIV infected children three years and older in a resource-limited setting, an LPVr induction- nevirapine maintenance strategy resulted in more initial virological suppression and similar incidence of virological failure after initial virological suppression than NNRTI-based regimens.

Temporal changes in the outcomes of HIV-exposed infants in Kinshasa, Democratic Republic of Congo during a period of rapidly evolving guidelines for care (2007-2013)

OBJECTIVE

Guidelines for prevention of mother-to-child transmission of HIV have developed rapidly, yet little is known about how outcomes of HIV-exposed infants have changed over time. We describe HIV-exposed infant outcomes in Kinshasa, Democratic Republic of Congo, between 2007 and 2013.

DESIGN

Cohort study of mother-infant pairs enrolled in family-centered comprehensive HIV care.

METHODS

Accounting for competing risks, we estimated the cumulative incidences of early infant diagnosis, HIV transmission, death, loss to follow-up, and combination antiretroviral therapy (cART) initiation for infants enrolled in three periods (2007-2008, 2009-2010, and 2011-2012).

RESULTS

1707 HIV-exposed infants enrolled at a median age of 2.6 weeks. Among infants whose mothers had recently enrolled into HIV care (N = 1411), access to EID by age two months increased from 28% (95% confidence limits [CL]: 24,34%) among infants enrolled in 2007-2008 to 63% (95% CL: 59,68%) among infants enrolled in 2011-2012 (Gray's p-value <0.01). The 18-month cumulative incidence of HIV declined from 16% (95% CL: 11,22%) for infants enrolled in 2007-2008 to 11% (95% CL: 8,16%) for infants enrolled in 2011-2012 (Gray's p-value = 0.19). The 18-month cumulative incidence of death also declined, from 8% (95% CL: 5,12%) to 3% (95% CL: 2,5%) (Gray's p-value = 0.02). LTFU did not improve, with 18-month cumulative incidences of 19% (95% CL: 15,23%) for infants enrolled in 2007-2008 and 22% (95% CL: 18,26%) for infants enrolled in 2011-2012 (Gray's p-value = 0.06). Among HIV-infected infants, the 24-month cumulative incidence of cART increased from 61% (95% CL: 43,75%) to 97% (95% CL: 82,100%) (Gray's p-value <0.01); the median age at cART decreased from 17.9 to 9.3 months. Outcomes were better for infants whose mothers enrolled before pregnancy.

CONCLUSIONS

We observed encouraging improvements, but continued efforts are needed.

Directly-observed intermittent therapy versus unsupervised daily regimen during the intensive phase of antituberculosis therapy in HIV infected patients

The World Health Organization strongly recommends using daily antituberculosis therapy (ATT) during the intensive phase for HIV infected patients. India has the highest burden of tuberculosis in the world, but HIV infected patients are still receiving intermittent ATT. In this study we compared the mortality in patients who received directly-observed intermittent ATT versus self-administered daily ATT with fixed dose combinations during the intensive phase in a context of freely available antiretroviral therapy. The study included 1460 patients, 343 in the intermittent ATT group and 1117 in the daily ATT group. Baseline covariates of the two groups were balanced using inverse probability of treatment weighting based on propensity score methods. In a sensitivity analysis, continuous variables (albumin, CD4 count, and age) were modelled using restricted cubic smoothing splines. Compared with patients who received daily ATT, patients who received intermittent ATT had a 40% higher risk of mortality (1.4 hazard ratio; 95% confidence interval, 1.14-1.7). We estimated that the use of daily ATT could achieve a 10% absolute reduction in mortality at 12 months. Self-administered daily ATT was not associated with an increased risk of default from treatment. These results support the immediate implementation of daily ATT for HIV infected patients during the intensive phase in India.

Optimal Duration of Daily Antituberculosis Therapy before Switching to DOTS Intermittent Therapy to Reduce Mortality in HIV Infected Patients: A Duration-Response Analysis Using Restricted Cubic Splines

Compared with thrice-weekly intermittent antituberculosis therapy (ATT), the use of daily ATT during the intensive phase has shown improved survival in HIV infected patients with tuberculosis. However, the optimal duration of daily ATT before initiating intermittent ATT is not well known. In this study, we analysed the mortality of HIV-related tuberculosis according to the duration of daily ATT before switching to thrice-weekly ATT in patients who completed at least two months of treatment in an HIV cohort study. Statistical analysis was performed using Cox proportional hazard models. To relax the linearity assumption in regression models and to allow for a flexible interpretation of the relationship between duration of daily ATT and mortality, continuous variables were modelled using restricted cubic splines. The study included 520 HIV infected patients with tuberculosis and 8,724.3 person-months of follow-up. The multivariable analysis showed that the mortality risk was inversely correlated with the duration of daily ATT before switching to intermittent therapy during the first 30 days of ATT but, after approximately 30 days of treatment, differences were not statistically significant. The results of this study suggest that daily ATT should be given for at least 30 days before switching to intermittent ATT in HIV infected patients with tuberculosis.

Knowledge, attitudes and practices regarding infant feeding among HIV-infected pregnant women in Gaborone, Botswana: a cross-sectional survey

OBJECTIVES

To assess knowledge, attitudes and practices regarding infant feeding among HIV-positive pregnant women in Gaborone, Botswana, and factors that influence their infant feeding choices.

DESIGN

A cross-sectional study.

METHODS AND STUDY SETTING

A questionnaire survey of 96 HIV-positive pregnant women attending four public infectious disease control clinics in Gaborone, Botswana.

RESULTS

Only about half of the study participants had knowledge about prevention of mother-to-child transmission (PMTCT) services related to breastfeeding, and very few (19.8%) chose to breastfeed their infants exclusively. Results of multiple logistic regression analysis showed that receiving infant feeding counselling as part of the PMTCT programme was significantly associated with a decision to exclusively breastfeed (OR (95% CI) 5.38 (1.83 to 15.81)). Similarly, HIV-positive pregnant women who received breastfeeding counselling through the PMTCT programme had higher knowledge of PMTCT practices related to appropriate infant feeding (OR (95% CI) 5.91 (1.06 to 34.31)). Women who did not express concern about HIV stigma had significantly higher knowledge of PMTCT practices related to infant feeding (OR (95% CI) 5.91 (1.69 to 15.56)). Knowledge of PMTCT practices related to breastfeeding was negatively associated with the belief that breastfeeding could transmit HIV to the baby (OR (95% CI) 9.73 (3.37 to 28.08)).

CONCLUSIONS

Knowledge, attitudes and practices related to breastfeeding among HIV-positive pregnant women need further improvement, and the PMTCT programme should strengthen infant feeding counselling services to assist HIV-positive mothers in making informed and appropriate decisions regarding infant feeding.

Predictors of delayed entry into medical care of children diagnosed with HIV infection: data from an HIV cohort study in India

Data about the attrition before entry into care of children diagnosed with HIV in low- or middle-income countries are scarce. The aim of this study is to describe the attrition before engagement in HIV medical care in 523 children who were diagnosed with HIV from 2007 to 2012 in a cohort study in India. The cumulative incidence of children who entered into care was 87.2% at one year, but most children who did not enter into care within one year were lost to followup. The mortality before entry into care was low (1.3% at one year) and concentrated during the first three months after HIV diagnosis. Factors associated with delayed entry into care were being diagnosed after mother's HIV diagnosis, belonging to scheduled castes, age <18 months, female gender, and living >90 minutes from the HIV centre. Children whose parents were alive and were living in a rented house were at a higher risk of delayed entry into care than those who were living in an owned house. The results of this study can be used to improve the linkage between HIV testing and HIV care of children diagnosed with HIV in India.

Predictors of delayed antiretroviral therapy initiation, mortality, and loss to followup in HIV infected patients eligible for HIV treatment: data from an HIV cohort study in India

Studies from Sub-Saharan Africa have shown that a substantial number of HIV patients eligible for antiretroviral therapy (ART) do not start treatment. However, data from other low- or middle-income countries are scarce. In this study, we describe the outcomes of 4105 HIV patients who became ART eligible from January 2007 to November 2011 in an HIV cohort study in India. After three years of ART eligibility, 78.4% started ART, 9.3% died before ART initiation, and 10.3% were lost to followup. Diagnosis of tuberculosis, being homeless, lower CD4 count, longer duration of pre-ART care, belonging to a disadvantaged community, being widowed, and not living near a town were associated with delayed ART initiation. Diagnosis of tuberculosis, being homeless, lower CD4 count, shorter duration of pre-ART care, belonging to a disadvantaged community, illiteracy, and age >45 years were associated with mortality. Being homeless, being single, not living near a town, having a CD4 count <150 cells/μL, and shorter duration of pre-ART care were associated with loss to followup. These results highlight the need to improve the timely initiation of ART in HIV programmes in India, especially in ART eligible patients with tuberculosis, low CD4 counts, living in rural areas, or having a low socioeconomic status.

Predictors of attrition in patients ineligible for antiretroviral therapy after being diagnosed with HIV: data from an HIV cohort study in India

In newly HIV-diagnosed patients, the CD4+ lymphocyte count is measured to determine the need for antiretroviral therapy (ART). Studies from Sub-Saharan Africa have shown that patients who are ART ineligible at the first assessment have poor retention in care, but data from other low- or middle-income countries are scarce. In this study we describe the retention in pre-ART care of 1696 patients who were ineligible for ART after being diagnosed with HIV in a cohort study in India. More than one-third of ART ineligible patients had poor retention in care, and the attrition was higher in those with longer follow-up periods. Of those patients with poor retention, only 10% came back to the clinics, and their CD4 cell counts were lower than the ones of patients retained in care. After 4.5 years of follow-up, the cumulative incidence of loss to follow-up was 50%. Factors associated with attrition were being homeless, being illiterate, belonging to a disadvantaged community, being symptomatic at the time of the HIV diagnosis, male gender, and not living near a town. Widows were given nutritional support and, therefore, had better retention in care. The results of this study highlight the need to improve the retention in care of ART ineligible patients in India.

Factors associated with delayed entry into HIV medical care after HIV diagnosis in a resource-limited setting: Data from a cohort study in India

Studies from sub-Saharan Africa have shown that a substantial proportion of patients diagnosed with HIV enter into HIV medical care late. However, data from low or middle-income countries outside Africa are scarce. In this study, we investigated risk factors associated with delayed entry into care stratified by gender in a large cohort study in India. 7701 patients were diagnosed with HIV and 5410 entered into care within three months of HIV diagnosis. Nearly 80% entered into care within a year, but most patients who did not enter into care within a year remained lost to follow up or died. Patient with risk factors related to having a low socio-economic status (poverty, being homeless, belonging to a disadvantaged community and illiteracy) were more likely to enter into care late. In addition, male gender and being asymptomatic at the moment of HIV infection were factors associated with delayed entry into care. Substantial gender differences were found. Younger age was found to be associated with delayed entry in men, but not in women. Widows and unmarried men were more likely to enter into care within three months. Women belonging to disadvantaged communities or living far from a town were more likely to enter into care late. The results of this study highlight the need to improve the linkage between HIV diagnosis and HIV treatment in India. HIV programmes should monitor patients diagnosed with HIV until they engage in HIV medical care, especially those at increased risk of attrition.

Effectiveness of a prevention of mother-to-child HIV transmission program in Guangdong province from 2007 to 2010

Background

To achieve the goal of United Nations of elimination of new HIV infections, a program of prevention of mother-to-child transmission (PMTCT) was launched in Guangdong province. The objective of this study is to evaluate the effectiveness of the PMTCT program.

Methods

The retrospective cross-section analysis was conducted using the data of case reported cards of HIV positive mothers and their infants from 2007 to 2010 in Guangdong province, and 108 pairs of eligible subjects were obtained. We described the data and compared the rates of MTCT by various PMTCT interventions respectively.

Results

The overall rate of HIV MTCT was 13.89% (15) among 108 pairs of HIV positive mothers and their infants; 60.19% (65) of the mothers ever received ARVs, 80.56% (87) of infants born to HIV positive mothers ever received ARVs, but 16.67% (18) of the mothers and infants neither received ARVs. Among all the mothers and infants, who both received ARVs, received triple ARVs, mother received ARVs during pregnancy, and both received ARVs and formula feeding showed the lower rates of HIV MTCT, and the rates were 8.06%, 2.50%, 5.77%, and 6.67% respectively. In infants born to HIV positive mother, who received mixed feeding had a higher HIV MTCT up to 60.00%. Delivery mode might not relative to HIV MTCT.

Conclusions

The interventions of PMTCT program in Guangdong could effectively reduce the rate of HIV MTCT, but the effectiveness of the PMTCT program were heavily cut down by the lower availability of the PMTCT interventions.

Severe malnutrition among children under the age of 5 years admitted to a rural district hospital in southern Mozambique

OBJECTIVE

To describe the burden, clinical characteristics and prognostic factors of severe malnutrition in children under the age of 5 years.

DESIGN

Retrospective study of hospital-based data systematically collected from January 2001 to December 2010.

SETTING

Rural Mozambican district hospital.

SUBJECTS

All children aged <5 years admitted with severe malnutrition.

RESULTS

During the 10-year long study surveillance, 274 813 children belonging to Manhiça’s Demographic Surveillance System were seen at out-patient clinics, almost half of whom (47 %) presented with some indication of malnutrition and 6% (17 188/274 813) with severe malnutrition. Of these, only 15% (2522/17 188) were eventually admitted. Case fatality rate of severe malnutrition was 7% (162/2274). Bacteraemia, hypoglycaemia, oral candidiasis, prostration, oedema, pallor and acute diarrhoea were independently associated with an increased risk of in-hospital mortality, while malaria parasitaemia and breast-feeding were independently associated with a lower risk of a poor outcome. Overall minimum communitybased incidence rate was 15 cases per 1000 child-years at risk and children aged 12–23 months had the highest incidence.

CONCLUSIONS

Severe malnutrition among admitted children in this Mozambican setting was common but frequently went undetected, despite being associated with a high risk of death. Measures to improve its recognition by clinicians responsible for the first evaluation of patients at the out-patient level are urgently needed so as to improve their likelihood of survival. Together with this, the rapid management of complications such as hypoglycaemia and concomitant co-infections such as bacteraemia, acute diarrhoea, oral candidiasis and HIV/AIDS may contribute to reverse the intolerable toll that malnutrition poses in the health of children in rural African settings.